INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on January 25, 2024 by staff from the Department of Drug and Alcohol Programs, Bureau of Program Licensure. Based on the findings of the on-site inspection, Avise Wellness was found not to be in compliance with the applicable chapters of 28 PA Code which pertain to the facility. The following deficiencies were identified during this inspection:
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Plan of Correction
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704.3 (b) LICENSURE Recruitment and Hiring
704.3. General requirements for projects.
(b) The project shall develop a policy that addresses the recruitment and hiring of staff persons who are appropriate to the population to be served. Every effort shall be made to hire staff persons representative of that population.
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Observations
Based on an administrative review of the facility policy and procedure manual, the facility failed to develop a policy that addresses the recruitment and hiring of staff persons who are appropriate to the population served, including that every effort shall me made to hire staff persons representative of that population.
This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
The hiring policy (#10.008) was amended to include that every effort shall be made to hire staff persons representative of the population being served.
Our philosophy at Avise Wellness has been to hire individuals representative of that population since we opened.
Currently all staff are representative of that population.
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705.28 (c) (4) LICENSURE Fire safety.
705.28. Fire safety.
(c) Fire extinguishers. The nonresidential facility shall:
(4) Instruct staff in the use of the fire extinguisher upon staff employment. This instruction shall be documented by the facility.
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Observations
Based on a review of personnel records, the facility failed to instruct all staff in the use of the fire extinguisher upon employment in three of three applicable personnel records reviewed.
Employee # 1 was hired as the project director and facility director on October 30, 2023. The training in the use of fire extinguishers was not completed until January 24, 2024.
Employee # 2 was hired as a clinical supervisor on January 2, 2024. The training in the use of fire extinguishers was not completed until January 24, 2024.
Employee # 3 was hired as a counselor on June 1, 2023. The training in the use of fire extinguishers was not completed until January 24, 2024.
This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
All staff will be required to complete fire extinguisher training within the first 7 days of hire as part of the orientation process. This is highlighted in policy #10.013.
It is the responsibility of the Clinical Director to ensure that all training has been done during the orientation process.
The CEO will review training files to ensure compliance with this policy. |
705.28 (d) (1) LICENSURE Fire safety.
705.28. Fire safety.
(d) Fire drills. The nonresidential facility shall:
(1) Conduct unannounced fire drills at least once a month.
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Observations
Based on a review of the facility's July 2023 through January 2024 fire drill log, the facility failed to ensure that unannounced fire drills were conducted at least once a month.
There were no documented fire drills conducted during the months of July 2023 through November 2023.
This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
Since December of 2023, fire drills have occurred as a part of our monthly practice. The Safety Officer is responsible for conducting fire drills on a monthly basis and will ensure that alternative entrances are used and that it occurs during different shifts.
The Project Director will follow up in supervision with the Safety Officer to ensure that all fire drills are being conducted in accordance with the policy. |
709.28 (c) LICENSURE Confidentiality
§ 709.28. Confidentiality.
(c) The project shall obtain an informed and voluntary consent from the client for the disclosure of information contained in the client record.
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Observations
Based on a review of client records, the facility failed to complete an informed and voluntary consent to release information form prior to the disclosure of information in four of six applicable client records reviewed.
Client # 1 was admitted to the outpatient activity on November 29, 2023 and was still active at the time of the inspection. There was evidence of disclosures to the funding source during the client's treatment episode; however, the consent to release information form was not signed by the client until January 24, 2024. There was no release form for any of the disclosures prior to January 24, 2024.
Client # 3 was admitted to the outpatient activity on December 22, 2023 and was still active at the time of the inspection. There was evidence of disclosures to the funding source during the client's treatment episode; however, the consent to release information form was not signed by the client until January 24, 2024. There was no release form for any of the disclosures prior to January 24, 2024.
Client # 4 was admitted to the outpatient activity on September 22, 2023 and was discharged on January 5, 2024. There was evidence of disclosures to the funding source during the client's treatment episode; however, there was no consent to release information form signed by the client documented in the record prior to any of the disclosures.
Client # 5 was admitted to the outpatient activity on October 2, 2023 and was discharged on December 29, 2023. There was evidence of disclosures to the funding source during the client's treatment episode; however, there was no consent to release information form signed by the client documented in the record prior to any of the disclosures.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
As a part of our new intake process and admissions SOP, all clients have Release of Information (ROI) that is automatically populated for funder, emergency contact, legal entity, family member, and laboratory. These forms must be completed prior to completing the biopsychosocial evaluation.
When the BPS and ROIs are completed and ready for review, the admin staff will review the new client record to ensure that all appropriate ROIs were signed and all info was completed accurately and appropriately. |
709.28 (c) (1) LICENSURE Confidentiality
§ 709.28. Confidentiality.
(c) The project shall obtain an informed and voluntary consent from the client for the disclosure of information contained in the client record. The consent must be in writing and include, but not be limited to:
(1) Name of the person, agency or organization to whom disclosure is made.
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Observations
Based on a review of client records, the facility failed to document the name of the person, agency, or organization to whom the disclosure is made on a consent to release information form in two of six applicable client records reviewed.
Client # 1 was admitted to the outpatient activity on November 29, 2023 and was still active at the time of the inspection. The release of information form to the funding source was signed and dated by the client and witness on January 24, 2024; however, the form did not include the name of the person, agency, or organization to whom the disclosure would be made.
Client # 3 was admitted to the outpatient activity on December 22, 2023 and was still active at the time of the inspection. The release of information form to the funding source was signed and dated by the client and witness on January 24, 2024; however, the form did not include the name of the person, agency, or organization to whom the disclosure would be made.
This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
As a part of our new intake process and admissions SOP, all clients have Release of Information (ROI) that is automatically populated for funder, emergency contact, legal entity, family member, and laboratory. These forms must be completed prior to completing the biopsychosocial evaluation.
When the BPS and ROIs are completed and ready for review, the admin staff will review the new client record to ensure that all appropriate ROIs were signed and all info was completed accurately and appropriately. In particular, admin staff will check to ensure that the name of the funding source was added to the ROI.
Client #1 and #3 that did not have the funder source listed were immediately corrected and the funder source was added to the ROI. |
709.28 (c) (6) LICENSURE Confidentiality
§ 709.28. Confidentiality.
(c) The project shall obtain an informed and voluntary consent from the client for the disclosure of information contained in the client record. The consent must be in writing and include, but not be limited to:
(6) Date, event or condition upon which the consent will expire.
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Observations
Based on a review of client records, the facility failed to document the date, event, or condition upon which the consent will expire on consent to release information forms in two of six applicable client records reviewed.
Client # 5 was admitted to the outpatient activity on October 2, 2023 and was discharged on December 29, 2023. The release of information form to a physician was signed by the client on October 20, 2023, but the release form did not include the date, event, or condition upon which the consent would expire.
Client # 7 was admitted to the outpatient activity on October 6, 2023 and was discharged on November 3, 2023. The release of information forms to an emergency contact and the funding source were signed by the client on October 6, 2023, but the release form did not include the date, event, or condition upon which the consents would expire.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Effective December 2023, the Project Director implemented all new ROIs into the EHR and all ones have been deleted.
Every single ROI now includes the date/event/condition upon which the consent with expire.
All staff have been trained to ensure ROIs are completed appropriately. Clinical Director does biweekly chart audits to ensure that all ROIs are in the chart. In team meetings, admin staff review charting expectations. |
709.28 (d) LICENSURE Confidentiality
§ 709.28. Confidentiality.
(d) A copy of a client consent shall be offered to the client and a copy maintained in the client record.
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Observations
Based on a review of client records, the facility failed to document that a copy of a client consent was offered to the client in each release of information form in five of six applicable client records reviewed.
Client # 1 was admitted to the outpatient activity on November 29, 2023 and was still active at the time of the inspection. The release of information form to the emergency contact was signed by the client on November 29, 2023, but there was no documentation indicating a copy of the consent form was offered to the client.
Client # 2 was admitted to the outpatient activity on December 19, 2023 and was still active at the time of the inspection. The release of information forms to the emergency contact, the funding source and a laboratory were signed by the client on December 19, 2023, but there was no documentation indicating that a copy of any of the consent forms were offered to the client.
Client # 3 was admitted to the outpatient activity on December 22, 2023 and was still active at the time of the inspection. The release of information form to the emergency contact was signed by the client on December 22, 2023, but there was no documentation indicating a copy of the consent form was offered to the client.
Client # 5 was admitted to the outpatient activity on October 2, 2023 and was discharged on December 29, 2023. The release of information form to a physician was signed by the client on October 20, 2023, but there was no documentation indicating a copy of the consent form was offered to the client.
Client # 7 was admitted to the outpatient activity on October 6, 2023 and was discharged on November 3, 2023. The release of information forms to the emergency contact and the funding source were signed by the client on October 6, 2023, but there was no documentation indicating that a copy of any of the consent forms were offered to the client.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Effective December 2023, all new ROIs have been added to the system and every one includes a check box for whether the client accepts or refuses a copy of the release.
Client #3 did have this indicated on the emergency contact release that he declined a copy.
Any prior version of the ROI has been deleted from the EHR.
All staff have been trained to ensure ROIs are completed appropriately. Clinical Director does biweekly chart audits to ensure that all ROIs are in the chart. In team meetings, admin staff review charting expectations. |
709.32 (c) (2) LICENSURE Medication control
§ 709.32. Medication control.
(c) The project shall have and implement a written policy and procedures regarding all medications used by clients which shall include, but not be limited to:
(2) Drug storage areas including, but not limited to, the secure storage of controlled substances and other abusable drugs in accordance with State and Federal regulations and program requirements.
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Observations
Based on an administrative review of the policy and procedure manual, the facility failed to include, in their medication control policy, indication of the secure storage of controlled substances and other abusable drugs in accordance with State and Federal regulations and program requirements.
This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
On 2/12/24, Policy # 6.007 was updated to include the necessary information-
The medication will remain securely locked in an office next to the CEO's office. One key will be provided to the Medical Director and the other key will be provided to the CEO.
The medication will be secured and when medication is entered into the fridge, it will be entered into a medication record sheet, which will include name and dose of medication, date and time the medication was entered into the fridge, date and time the medication was removed from the fridge and by who (staff name and initials).
Any medication errors or drug reactions will be included in the client's medical record under the medical section in a progress note. |
709.32 (c) (3) (i) - (v) LICENSURE Medication control
§ 709.32. Medication control.
(3) Inspection of storage areas that ensures compliance with State and Federal laws and program policy. The policy must include, but not be limited to:
(i) What is to be verified through the inspection, who inspects, how often, but not less than quarterly, and in what manner it is to be recorded.
(ii) Disinfectants and drugs for external use are stored separately from oral and injectable drugs.
(iii) Drugs requiring special conditions for storage to insure stability are properly stored.
(iv) Outdated drugs are removed.
(v) Copies of drug-related regulations are available in appropriate areas.
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Observations
Based on an administrative review of the policy and procedure manual, the facility failed to include, in their medication control policy, that outdated drugs are to be removed and that copies of drug-related regulations are available in the appropriate areas.
This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
Policy # 6.007 has been updated to include:
The medication will remain securely locked and the key will be provided to the Medical Director and another key will be provided to the CEO. The medication will be secured and when medication is entered into the fridge, it will be entered into a medication record sheet, which will include name and dose of medication, date and time the medication was entered into the fridge, date and time the medication was removed from the fridge and by who (staff name and initials). Any medication errors or drug reactions will be included in the client's medical record under the medical section in a progress note.
Any outdated medications, will be removed from the medication refrigerator by the medical personnel only. In addition, copies of drug related regulations will be available to be reviewed by the client.
No other medications are to be administered, stored, safe handled, or disposed of at the facility.
The Project Director will ensure that this medication record is completed and that the policy and procedure is adhered to, on a regular basis. |
709.32 (c) (4) (i) - (ii) LICENSURE Medication control
§ 709.32. Medication control.
(4) Methods for control and accountability of drugs, including, but not limited to:
(i) Who is authorized to remove drug.
(ii) The program ' s system for recording drugs, which includes the name of the drug, the dosage, the staff person, the time and the date.
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Observations
Based on an administrative review of the policy and procedure manual, the facility failed to include, in their medication control policy, all methods for control and accountability of drugs, including who is authorized to remove the drug.
This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
Policy # 6.007 has been updated to include:
The medication will remain securely locked and the key will be provided to the Medical Director and another key will be provided to the CEO. The medication will be secured and when medication is entered into the fridge, it will be entered into a medication record sheet, which will include name and dose of medication, date and time the medication was entered into the fridge, date and time the medication was removed from the fridge and by who (staff name and initials). Any medication errors or drug reactions will be included in the client's medical record under the medical section in a progress note.
Any outdated medications, will be removed from the medication refrigerator by the medical personnel only. In addition, copies of drug related regulations will be available to be reviewed by the client.
No other medications are to be administered, stored, safe handled, or disposed of at the facility.
The Project Director will ensure that this medication record is completed and that the policy and procedure is adhered to, on a regular basis. |
709.32 (c) (5) LICENSURE Medication control
§ 709.32. Medication control.
(5) Security of drugs, including, but not limited to, the loss, theft or misuse of drugs.
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Observations
Based on an administrative review of the policy and procedure manual, the facility failed to include, in their medication control policy, a policy and procedures of ho the facility would handle the security of drugs, including the loss, theft or misuse of drugs.
This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
Policy # 6.007 has been updated to include:
The medication will remain securely locked and the key will be provided to the Medical Director and another key will be provided to the CEO. The medication will be secured and when medication is entered into the fridge, it will be entered into a medication record sheet, which will include name and dose of medication, date and time the medication was entered into the fridge, date and time the medication was removed from the fridge and by who (staff name and initials). Any medication errors or drug reactions will be included in the client's medical record under the medical section in a progress note.
Any outdated medications, will be removed from the medication refrigerator by the medical personnel only. In addition, copies of drug related regulations will be available to be reviewed by the client.
No other medications are to be administered, stored, safe handled, or disposed of at the facility.
The Project Director will ensure that this medication record is completed and that the policy and procedure is adhered to, on a regular basis. |
709.32 (c) (6) LICENSURE Medication control
§ 709.32. Medication control.
(6) Medication errors and drug reactions shall be recorded in the client record. This may be the medical record if a separate medical record is maintained for all clients.
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Observations
Based on an administrative review of the policy and procedure manual, the facility failed to include, in their medication control policy, the procedure that medication errors and drug reactions shall be recorded in the client record.
This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
Policy # 6.007 has been updated to include:
The medication will remain securely locked and the key will be provided to the Medical Director and another key will be provided to the CEO. The medication will be secured and when medication is entered into the fridge, it will be entered into a medication record sheet, which will include name and dose of medication, date and time the medication was entered into the fridge, date and time the medication was removed from the fridge and by who (staff name and initials). Any medication errors or drug reactions will be included in the client's medical record under the medical section in a progress note.
Any outdated medications, will be removed from the medication refrigerator by the medical personnel only. In addition, copies of drug related regulations will be available to be reviewed by the client.
No other medications are to be administered, stored, safe handled, or disposed of at the facility.
The Project Director will ensure that this medication record is completed and that the policy and procedure is adhered to, on a regular basis. |
709.91(b)(2)(i) LICENSURE Intake and admission
709.91. Intake and admission.
(b) Intake procedures shall include documentation of:
(2) Client orientation to the project which shall include, but is not limited to, a familiarization with the following:
(i) Project policies.
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Observations
Based on a review of client records, the facility failed to document client orientation to the project during the intake and admission process in seven of seven applicable client records reviewed.
Client # 1 was admitted to the outpatient activity on November 29, 2023 and was still active at the time of the inspection. The documentation of client orientation to the project was not completed until January 24, 2024.
Client # 2 was admitted to the outpatient activity on December 19, 2023 and was still active at the time of the inspection. The documentation of client orientation to the project was not completed until January 24, 2024.
Client # 3 was admitted to the outpatient activity on December 22, 2023 and was still active at the time of the inspection. The documentation of client orientation to the project was not completed until January 24, 2024.
Client # 4 was admitted to the outpatient activity on September 22, 2023 and was discharged on January 5, 2024. There was no documentation of client orientation to the project in the record at the time of the inspection.
Client # 5 was admitted to the outpatient activity on October 2, 2023 and was discharged on December 29, 2023. There was no documentation of client orientation to the project in the record at the time of the inspection.
Client # 6 was admitted to the outpatient activity on September 22, 2023 and was discharged on November 3, 2023. There was no documentation of client orientation to the project in the record at the time of the inspection.
Client # 7 was admitted to the outpatient activity on October 6, 2023 and was discharged on November 3, 2023. There was no documentation of client orientation to the project in the record at the time of the inspection.
These findings were reviewed with facility staff during the licensing inspection.
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Plan of Correction
As a part of the new admissions SOP, all clients will have orientation to project on the day of assessment. The evidence of this will be that they signed that they received a copy of the client handbook. This can be provided electronically or in paper format.
When the BPS and ROIs are completed and ready for review, admin staff will review it to ensure that all appropriate forms are signed and completed accurately and appropriately. |
709.91(b)(7) LICENSURE Intake and admission
709.91. Intake and admission.
(b) Intake procedures shall include documentation of:
(7) Preliminary treatment and rehabilitation plan.
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Observations
Based on a review of client records, the facility failed to document, as part of their intake and admission process, a preliminary treatment and rehabilitation plan in four of seven applicable client records reviewed.
The facility policy and procedure manual stated that the preliminary treatment plan will be completed within three days of admission.
Client # 1 was admitted to the outpatient activity on November 29, 2023 and was still active at the time of the inspection. The preliminary treatment plan was due to be completed no later than December 2, 2023; however, the plan was not completed until December 6, 2023.
Client # 3 was admitted to the outpatient activity on December 22, 2023 and was still active at the time of the inspection. There was no preliminary treatment plan documented in the client record at the time of the inspection.
Client # 4 was admitted to the outpatient activity on September 22, 2023 and was discharged on January 5, 2024. The preliminary treatment plan was due to be completed no later than September 25, 2023; however, the plan was not completed until October 5, 2023.
Client # 7 was admitted to the outpatient activity on October 6, 2023 and was discharged on November 3, 2023. There was no preliminary treatment plan documented in the client record at the time of the inspection.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
As a part of the new admissions SOP, all clients will have their initial treatment plan completed at the time of the BPS along with the other intake forms.
When the BPS, intake forms and initial treatment plan are completed and ready for review, admin staff will review it to ensure that all appropriate forms are signed and completed accurately and appropriately. |
709.92(a) LICENSURE Treatment and rehabilitation services
709.92. Treatment and rehabilitation services.
(a) An individual treatment and rehabilitation plan shall be developed with a client. This plan shall include, but not be limited to, written documentation of:
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Observations
Based on a review of client records, the facility failed to ensure individual treatment and rehabilitation plans were developed with the client in three of six applicable client records reviewed.
The facility policy and procedure manual stated that the individual treatment and rehabilitation plan will be completed within thirty days of admission.
Client # 4 was admitted to the outpatient activity on September 22, 2023 and was discharged on January 5, 2024. The individual treatment and rehabilitation plan was due to be completed no later than October 22, 2023; however, the plan was not completed until December 6, 2023 and there was no documentation that the plan was completed with input from the client.
Client # 5 was admitted to the outpatient activity on October 2, 2023 and was discharged on December 29, 2023. The individual treatment and rehabilitation plan was due to be completed no later than November 2, 2023; however, the plan was not completed until November 27, 2023 and there was no documentation that the plan was completed with input from the client.
Client # 6 was admitted to the outpatient activity on September 22, 2023 and was discharged on November 3, 2023. The individual treatment and rehabilitation plan was completed on October 5, 2023; however, there was no documentation that the plan was completed with input from the client.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Effective December 2023, as a part of the new admissions SOP, all new clients will have a comprehensive treatment plan completed at the initial therapy session. All of the client records cited are from prior to this procedure change.
Once the treatment plan is signed by the client and the therapist, it will be required to be signed off on by admin staff. The admin staff will review it to ensure that it is signed by both parties and completed accurately and appropriately. |
709.92(a)(2) LICENSURE Treatment and rehabilitation services
709.92. Treatment and rehabilitation services.
(a) An individual treatment and rehabilitation plan shall be developed with a client. This plan shall include, but not be limited to, written documentation of:
(2) Type and frequency of treatment and rehabilitation services.
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Observations
Based on a review of client records, the facility failed to document the type and frequency of treatment services on the individual treatment and rehabilitation plan in five of six client records reviewed.
Client # 1 was admitted to the outpatient activity on November 29, 2023 and was still active at the time of the inspection. The individual treatment and rehabilitation plan was completed on December 6, 2023; however, the plan did not include the type and frequency of treatment and rehabilitation services.
Client # 2 was admitted to the outpatient activity on December 19, 2023 and was still active at the time of the inspection. The individual treatment and rehabilitation plan was completed on January 3, 2024; however, the plan did not include the type and frequency of treatment and rehabilitation services.
Client # 4 was admitted to the outpatient activity on September 22, 2023 and was discharged on January 5, 2024. The individual treatment and rehabilitation plan was completed on December 6, 2023; however, the plan did not include the type and frequency of treatment and rehabilitation services.
Client # 5 was admitted to the outpatient activity on October 2, 2023 and was discharged on December 29, 2023. The individual treatment and rehabilitation plan was completed on November 27, 2023; however, the plan did not include the type and frequency of treatment and rehabilitation services.
Client # 6 was admitted to the outpatient activity on September 22, 2023 and was discharged on November 3, 2023. The individual treatment and rehabilitation plan was completed on October 5, 2023; however, the plan did not include the type and frequency of treatment and rehabilitation services.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
As a part of the new admissions SOP, all clients will have their treatment plan include the type and frequency of treatment and rehabilitation services. To specify, it will be determined in the treatment plan, the number of sessions the client will attend each week as well as the type of services they will receive to meet their treatment goals, including group, individual and family therapy.
Once the treatment plan is signed off by the client and therapist, it will prompt an admin staff to review it to ensure that it is signed and completed accurately and appropriately.
Both active clients #1 and #2 had this added to their treatment plan update so it now reflects the type and frequency of services. |
709.93(a)(8) LICENSURE Client records
709.93. Client records.
(a) There shall be a complete client record on an individual which includes information relative to the client's involvement with the project. This shall include, but not be limited to, the following:
(8) Case consultation notes.
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Observations
Based on a review of client records, the facility failed to maintain a complete client record, which is to include case consultation notes, in seven of seven applicable client records reviewed.
In each outpatient activity client record reviewed, there were no case consultation notes documented at the time of the inspection.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
As a part of the new admissions process, the clients will have a case consultation at the time of their first step down/up to a new level of care and every step down/up thereafter.
In the event of specific situation with the client, a case consultation will be done and documented in the patient chart.
At treatment team meetings, the admin staff will require a case consultation when the therapist is presenting the client for a step down/up and this will be signed off on by admin staff in the client record. |